He Said What?

Dental insurance. There is so much to say about dental insurance. Most of it is not good. It is generally not good for the doctors that participate in the plans, and it is generally not good for our patients. But the fact is that more than half of the population is covered by some sort of dental “insurance” plan.

I recently had a claim denied. Please read the following response from the Senior Dental Consultant:

“Please go to our web site (if you have not already done so) and read the specific criteria for the Benefit Plan to allow payment for an indirect restoration (the criteria are exactly the same for any indirect restoration – crown, ¾ crown, onlay, veneer).

I agree with your statement below saying that some treatment should be considered based on the presence of what we are interpreting to be active disease (decay). However, the issue (from a Plan payment perspective) is the condition of this tooth does not meet those established criteria for payment. It certainly does not, in any way, mean that placing an indirect restoration is incorrect or inappropriate treatment – just that it does not meet criteria for the Benefit Plan to pay for it…

I hope you can understand why this decision was made – even if you do not agree with the decision.”

Basically what the dental consultant was, “You should have done something. What you

“Good is a point of view, Anakin.”

did wasn’t incorrect or inappropriate. We just aren’t going to cover it because of some arbitrary guidelines that have been set forth in the Plan.

These guidelines use words like “significant” and “reasonable” to quantify a clinical decision. This clinical decision was made by me and my patient, fully expecting the patient’s dental plan would fulfill its end of the bargain.

Apparently “significant and reasonable are a point of view.” And the person that writes the check is the only point of view that matters.

I fight every denial I receive for care that I render. I don’t need the money to run a successful business. But out of principal, no entity should be involved turning treatment decisions into financial decisions other than the patient and the healthcare provider whose opinion they are seeking.

I win most every denial I receive. But the fact remains, insurance companies can legally interfere with patient-doctor relationships essentially at will. That is wrong.

Tell me your stories. I’d love to hear how you fight insurance companies. I am also interested in your ideas regarding how we can correct this.